Augmented Nurse Care Management in CKD Stages 4 to 5: A Randomized Trial

• Published in: American journal of kidney diseases Vol. 70; no. 4; pp. 498 - 505
• Main Authors: Fishbane, Steven, MD, Agoritsas, Sofia, MPA, Bellucci, Alessandro, MD, Halinski, Candice, MSN, NP-C, Shah, Hitesh H., MD, Sakhiya, Vipul, MPH, Balsam, Leah, MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.10.2017
• Subjects: Aged; care management; Chronic kidney disease (CKD); Female; home dialysis; hospitalization; Humans; Kidney Failure, Chronic - nursing; kidney transplantation; late-stage CKD; Male; medical informatics; Middle Aged; Nephrology; nurse care manager; Nursing Process; patient education; peritoneal dialysis (PD); randomized controlled trial (RCT); Renal Insufficiency, Chronic - nursing; renal replacement therapy (RRT); RRT modality; Severity of Illness Index; transition of care; vascular access; hospitalization; randomized controlled trial (RCT); kidney transplantation; home dialysis; renal replacement therapy (RRT); Chronic kidney disease (CKD); care management; late-stage CKD; peritoneal dialysis (PD); medical informatics; patient education; nurse care manager; RRT modality; vascular access; transition of care
• ISSN: 0272-6386; 1523-6838
• DOI: 10.1053/j.ajkd.2017.02.366

Background Outcomes for patients with late-stage chronic kidney disease (CKD) in the United States are suboptimal. There is poor education and preparation for end-stage kidney disease, as well as a high rate of hospitalization in this group of patients. Study Design A randomized, parallel-group, 2-arm, controlled trial. Setting & Participants The study was conducted at 3 sites: a clinic of an academic medical center, a public hospital academic clinic, and a community-based private practice. All participants had late-stage CKD (stages 4-5 CKD). Patients were excluded only if they had significant cognitive impairment. Intervention The care management intervention involved nurse care manager coordination aided by the use of a disease-based informatics system for monitoring patients’ clinical status, enhancing CKD education, and facilitating preparation for end-stage kidney disease. The comparison control group received usual late-stage CKD care alone. Outcomes The primary outcome was rate of hospitalization. Measurements Rates of preemptive transplantation, home dialysis, hemodialysis (HD) starts without a hospitalization, and HD therapy initiation rates with catheters or with functioning accesses. Results 130 patients were randomly assigned. The hospitalization rate was significantly lower in the intervention group versus controls: 0.61 versus 0.92 per year, respectively (incidence rate ratio, 0.66; 95% CI, 0.43-0.99; P = 0.04). Peritoneal dialysis or preemptive transplantation was the initial end-stage kidney disease treatment in 11 of 30 (37%) participants receiving the intervention versus 3 of 29 (10%) receiving usual care. Among HD starts, treatment was initiated without hospitalization in 11 of 19 (58%) participants in the intervention group versus 6 of 26 (23%) in the control group. At the time of HD therapy initiation, a catheter was present in 7 of 19 (37%) participants in the intervention group versus 18 of 26 (69%) in the control group. A functioning arteriovenous access was in place in 10 of 19 (53%) participants in the intervention group and 7 of 26 (27%) in the control group Limitations Moderate sample size, limited geographic scope. Conclusions The augmented nurse care management intervention resulted in reduced hospitalizations in late-stage CKD and there were suggestions of improved end-stage kidney disease preparation. Given suboptimal outcomes in late-stage CKD, care management interventions could potentially improve patient outcomes.